Inadequate food safety knowledge and hygiene practices among street food vendors in Dhaka, Bangladesh

Food safety remains a critical issue with outbreaks of foodborne illness. The knowledge gap of food safety and improper hygienic practices of food handlers are the key factors for the transmission of foodborne diseases. This study was conducted to investigate the level of food safety knowledge and practices among street food vendors in Dhaka City, Bangladesh, and its implications on consumers’ health. This cross-sectional study was conducted among 350 respondents in seven areas of Dhaka City. Trained data collectors gather data by interviewing street vendors using a pretested questionnaire. Most of the vendors (98%) were male, with 48% having secondary education and 85% having no food safety training. Although about 89% of the vendors were found to practice hand washing, only a small proportion of them practised using hand gloves while handling raw products (5.6%), cleaning tables (2.2%), preparing foods (1.3%) or handling garbage (0.9%). The education level of the vendors and their work experience were significantly correlated with their hand washing practice, wearing hand gloves and their knowledge about food-borne illnesses. The study demonstrated that formal education played a significant role in vendors’ knowledge and practice of health safety measures for food handlers to prevent foodborne illness. Effective food safety training and monitoring are needed to increase vendors' knowledge and practices, and in reducing foodborne diseases.

Due to a significant number of incidences of food-borne diseases, the safety of street food is a major concern for developing countries 10 .A study of street vended foods in Bangladesh found high microbial contamination in the collected samples, including strains resistant to multiple drugs. 11.
Foodborne illnesses are often associated with inadequate food handling knowledge and expertise among food vendors.Some of the identified risk factors for foodborne illness include poor personal hygiene and sanitation, cross-contamination, inadequate cooking, improper storage, inadequate reheating, contaminated equipment, use of contaminated water, and purchasing raw foods from unreliable sources 12 .In most cases, street food vendors do not follow minimum hygiene practices, posing a high risk to the consumers' health 13 .A previous investigation carried out in Barisal City, Bangladesh, highlighted the inadequate food safety practices observed among the street food vendors 14 .
Limited studies in Bangladesh focus on food safety practices and knowledge among street vendors and their impact on consumer health.Therefore, it is crucial to identify the factors that affect safe food handling practices, particularly during preparation and serving.The existing literature did not use an adequate number of variables to understand the scenario.In our study, we have incorporated several factors that could be linked to vendors' knowledge and practices, highlighting the distinctiveness of our research.Additionally, many previous studies were unable to comprehensively cover all areas of Dhaka city in a single article due to their sampling methods.By including ten busy spots in Dhaka city in our sampling methods, our study's scientific robustness is underscored.This study will add value to the existing evidence of food safety knowledge among street food sellers in Dhaka City.

Research questions
The study addressed the following major research questions: (1) Do street food vendors know the importance of washing hands after handling raw materials, after cleaning food plates and tables, after handling garbage and before and after serving food?(2) Do street food vendors know the importance of wearing hand gloves?(3) Do food vendors know common health problems that can affect food safety?(5) What are their practices of hand washing and using hand gloves during food preparation, serving food, cleaning dishes, and handling garbage?

Questionnaire
A questionnaire was developed and pretested for data collection.The external validity of the questionnaire was primarily determined by literature review, and the internal validity was based on feedback from relevant experts and researchers in the field.The questionnaire was pretested in a sample of 15 people from the same locality of the study, and necessary modifications were made.
The questionnaire was composed of the following major areas: (1) Demographics including gender, age, family composition, and major occupation; Most of the questions were categorized as having yes, no, or don't know answers.The survey questions consisted of 13 items to measure the knowledge scores on hand washing, 8 items for the use of hand gloves, 19 items for types of food-borne illnesses, and 10 items for types of health problems that can affect food safety.Non-probability convenient technique was used for the collection of data.The Cronbach's Alpha was 0.74 on the questionnaire when considered separately in terms of knowledge and practice.A copy of the questionnaire is available in the appendix.
The survey was conducted by trained data collectors through in-person visits to the establishments.Three data collectors who had a minimum education of a bachelor's degree interviewed the participants.The data collectors were trained in the use of the questionnaire, and they received guidance on how to establish rapport with respondents.

Sample size estimation
For the baseline data, we used a cross-sectional study published by Nkosi and Tabit (2021) on the food safety knowledge of street food vendors in South Africa 15 .We used the conventional formula for cross-sectional study to calculate the sample size 16 , as follows: where, n = sample size, z = Z statistic for a level of confidence, p = expected prevalence, and d = precision.
The calculated sample size = 281.To adjust for an anticipated 10% nonresponse rate, the total sample = 309.We used 350 samples for the study.The power of the study was 80% 15,16 .

Statistical analysis
All statistical analyses were performed using the Statistical Package for the Social Sciences, Version 28.0 (SPSS, Inc., Chicago, IL, USA).Data on knowledge were classified into several sections -(1) Importance of hand Vol:.(1234567890) (3) Knowledge of food-borne diseases; and (4) Type of health problems that can affect food safety.For each correct answer, the respondent scored one point and for an incorrect answer, the respondent received a zero point.A composite score of knowledge was calculated by adding the knowledge score of the four categories of knowledge scores.The scores were computed, and the relation between the knowledge scores were compared with the educational level of the participants, the qualification of the head chef, work experience, and the type of vending facility.Descriptive statistics were assessed for data distribution.The mean knowledge scores were compared by using one-way ANOVA.A post-hoc test (Tukey's HSD) was computed for multiple comparisons and to identify which independent groups are significantly associated with the knowledge categories such as the practice of hand washing, wearing gloves, food-borne diseases, and type of health problems.Chi-square analysis was done to compare categorical variables such as each item of the four categories mentioned earlier and the head chef 's education status.A Pearson's correlation was computed between the variables.Multiple regression analyses were done to predict the composite knowledge score based on education, work experience, and qualification of the head chef.Findings with a p-value of ≤ 0.05 were considered statistically significant.

Demographic characteristics
The socio-economic and vending information (Table 1) of the participants show that most of the vendors were young adults aged 25 to 34 years.Regarding the educational level, 36.5% had completed primary education, and 47.7% had completed secondary education.Of the participants, 50.9% worked as chefs, 7.3% were cleaners, 23.3% were cutters, and 8.2% were food servers.Most participants (72.3%) said selling food on the street is their primary job.About half of them had 1 to 5 years of work experience, while 37% had 6 to 10 years of work experience.However, the majority (84.9%) never received food safety training.

Food safety knowledge
Figure 2 shows that about 53% of respondents mentioned that their hands should be washed after touching money, and 49.9% mentioned that they should wear gloves before touching ready-to-eat food products (Fig. 2).However, only a few mentioned the importance of washing hands after handling garbage (1.2%), raw foods (4.6%) and cleaning tables (8.2%).Health problems that can affect food safety were mentioned as follows: nausea (28.6%), coughing (23.9%), abdominal pain (16.0%), and diarrhoea (15.5%).Only 28% of the participants indicated that they should not handle foods, and a minority (2.2%) mentioned handling foods with gloves when they have cuts or abrasions on their hands, while 32% mentioned continuing work.Table 2 shows that nearly 90% of the participants claimed to have experience of foodborne illnesses and knew the signs and symptoms of these diseases.The majority (76.8%) mentioned abdominal pain and 13.2% mentioned watery diarrhea as common symptoms of food-borne diseases.Although 45% said they would stop work immediately when they are sick, 18.2% of participants said they would continue to work.

On-site observation of food handling practices
Table 3 shows that around 90% of the street vendors who were interviewed used gloves or washed their hands before handling food.However, about 77% only used gloves when handling ready-to-eat food products.About 5.6% of them were using gloves while handling raw foods.For cleaning cutting boards, 22.6% mentioned using detergents and hot water, and a large percentage (72.3%)mentioned rinsing the used knife under cold water only.Approximately 68% of the participants occasionally cleaned the spoons before using them again for the clients.Only 50.6% of the vendors used filtered water for cooking, compared to about 90.6% who used it for drinking.Approximately, 85% of them used tap water as the main source for cleaning utensils.

Factors associated with knowledge scores
Bivariate correlation analysis (Table 4) shows that the education level of the participants, work experience, and qualification of the head chef had a statistically significant relationship with knowledge about hand washing, wearing gloves, and food-borne illnesses (p < 0.001).However, no significant relationship has been achieved between work experience and knowledge about food-borne illnesses (p = 0.105).

Overall knowledge score by categories of head chef's qualification
Table 5 presents mean knowledge score calculated for four categories, such as knowledge on hand washing, knowledge on wearing hand gloves, knowledge on type of food-borne illness, and knowledge on health problems affecting food safety.Mean score of each of these categories were computed by using one-way ANOVA and Tukey's HSD post hoc test.Overall, the knowledge score of handwashing was higher than the other areas of knowledge.The head chef 's qualifications, including having certified on food safety and being trained on job in the restaurant had significantly higher knowledge scores in each of the four categories compared with those without any such qualifications.

Multiple regression analysis to predict knowledge scores
A composite score of knowledge of the four categories, including knowledge on hand washing, wearing hand gloves, the type of food-borne illnesses and the type of health problems that can affect food safety, was used as the dependent variables, and the head chef 's education, work experience and qualification were used as independent variables in a multiple regression analysis, using a stepwise method of model selection.

Relation between individual items of the knowledge categories and the head chef's qualification
For in-depth information, Chi-square analyses were conducted to find the relation between knowledge of individual items of each of the four categories and the head chef 's qualifications.Of the 15 questions (having yes and no answers) about knowledge of hand washing, 8 questions about wearing hand gloves, 19 questions about the types of food-borne diseases, and 20 questions on the types of health problems that can affect food safety, the head chef having certified on food safety provided significantly most correct answers on all items compared to chefs of other education categories, such as having a degree, diploma, trained on the job, or no education (p < 0.001 for all).A lack of knowledge of food handlers on many items related to food-borne diseases was identified.For example, they had adequate knowledge of common food-borne illnesses such as watery diarrhoea, nausea, and headache.In contrast, they had incorrect knowledge of items such as bloody diarrhoea, fatigue, and hypoglycemia, even when the head chefs were certified or diploma holders.

Discussion
In this study, we observed that the head chef 's education level, work experience, and qualification had a statistically significant relationship with the knowledge regarding hand washing, wearing gloves, and food-borne illnesses.
We also identified areas of inadequate knowledge and lack of healthy practices of street food vendors, which are likely to contribute toward the enormous burden of foodborne illnesses (such as watery diarrhoea, blood dysentery, salmonella infections, etc.) 5,17 .

Socioeconomic information n (%)
Fixed stall 150 (45.7) Mobile vending unit 169 (51.5) Restaurant/canteen 9 (2.7) Table 1.Socioeconomic and street vending background information of the study population.Numerous studies have consistently identified food handlers as the main contributors to food-borne diseases by using improper food handling practices 2,3 .Our findings regarding the infrequent washing of utensils, supplies for preparing food, and vendor hygiene standards are consistent with earlier studies, suggesting the importance of the cleanliness of street food preparations in reducing the source of contamination 4 .
Formal education has been found to significantly impact the knowledge and adherence of street vendors to health safety measures aimed at preventing foodborne illnesses.The knowledge and practices of street vendors are crucial factors in ensuring food safety 18 .An earlier study has found a strong positive correlation between attitude and practice (r = 0.839, p < 0.01) and between knowledge and practice (r = 0.835, p < 0.01) 19 .Akabanda et al. showed a strong link between positive attitude, behaviour and education of food handlers in maintaining safe food handling practice 18 .
Our findings regarding the infrequent washing of utensils, supplies for preparing food, and vendor hygiene standards are consistent with earlier research suggesting that the uncleanliness of street food preparations may be the source of contamination 20 .Personal hand hygiene is the most important factor in preventing food contamination 21 .Most of the studies found a lack of hygiene practices in food handlers and consumers or mishandling of the foods during the preparation, storage, and vending 18,22 .The food hygiene methods of the vendors need to be prioritized and require ongoing assistance and regular inspections by the public health authorities.In addition, interventional studies that include school health programs and public educational campaigns are important to raise awareness about foodborne outbreaks and the significance of personal hygiene in preventing diseases 23 .
Our study was consistent with several studies from different countries that reported low knowledge scores of street food vendors.However, the data of the current study on the hygiene practice of food handlers cannot be directly compared with other studies due to the variations in research questions, study samples, and the primary objectives of the studies.For example, a study was conducted among food handlers in a catering company in Portugal 24 , responsible for manufacturing and distributing food to schools, kindergartens and nursing establishments.Contrary to our report, a study in Ghana by Akabanda and co-workers (2017) 18 found that the food handlers demonstrated sufficient knowledge about hygiene practices such as hand washing, using gloves, and cleaning utensils properly.However, the sources for data collection of the Ghanaian population and our study differed.For example, the researchers in Ghana collected data on food handlers from various institutions such as schools, hospitals, universities, and health centers.On the other hand, we selected local street food vendors as our study participants.However, our study supports the findings of Nizame and his co-workers, who also demonstrated poor hygiene practices among street food vendors 5 .
Approximately 30 million people in Bangladesh suffer from foodborne diseases each year 25 , and there is a lack of proper sanitary facilities at the vending sites in the country.A study from Vietnam underscores the value of providing training and education to street food sellers to enhance their knowledge of food safety and hygiene Food vendors should also always practice proper hygiene.By following these guidelines, food contamination can be reduced, customers will benefit, and food-related diseases will be less prevalent.

Limitations
The present study had some limitations.As this is a cross-sectional study, we collected data after informing the study population about the purpose of our study, which might have resulted in reporting bias.Self-reporting of the vendors might be overestimated in their hygiene practices.Also, the study results should not be generalized to developed countries because of discrepancies in food hygiene regulations between developed and developing nations.
However, the study sample selection and data analysis methods were robust, as data from 10 spots in seven locations in busy city areas were included, and both univariate and multivariate analysis methods were employed.One of the unique aspects and novelty of this study is that we collected data through direct observation of food preparation and storage practices by the food handler.

Conclusions
In this study, a composite score of knowledge related to hand washing, wearing hand gloves, types of foodborne illnesses, and health issues affecting food safety was significantly predicted by the level of education and qualifications of the food handlers.The study results were unique and novel in the context of Bangladesh, where the consumption of street food is quite common.This information can be used to develop intervention efforts in street foods and prevent foodborne disease.Findings from this study should be helpful for the policymakers to take initiatives for legal enforcement for the implementation of good hygiene practices of street vendors.The health authorities may initiate an ongoing and informative food vendors' training program.Food handlers must take the initiative to engage in self-learning and stay updated.Regulatory authorities responsible for food safety should conduct proper inspections and educate vendors about correct food safety practices.They should also look for specific inappropriate food handling practices identified in the study and assist the street food vendors in correcting them.
(2) Experience, education and training; (3) Food safety knowledge; (a) Importance of hand washing; (b) Importance of using hand gloves; (c) Knowledge about food-borne diseases; and (d) Knowledge about health problems that can affect food safety; (4) Practice of food handlers on food safety measures; and (5) An on-site observation of their practices.

Figure 1 .
Figure 1.Study locations in Dhaka City, Bangladesh (marked as stars).

Figure 2 .
Figure 2. Food safety knowledge of the respondents.2(a) Importance of washing hands, 2(b) Importance of washing gloves, 2(c) Health problems that can affect food safety, 2(d) Actions needed if they have cuts or abrasion on hands.

Table 2 .
Knowledge and experience about food-borne diseases.

Table 5 .
Relation between food handler's knowledge score and the head chef 's qualification.*One-way ANOVA and Tukey's HSD test.

SD) Knowledge Score by Categories of Head Chef 's Qualification
vending areas.Designated garbage sites should be available for food vendors to dispose of their garbage properly.